Papillitis in a Typhoid fever patient with toxic encephalopathy and septic shock: a rare complication?

(1)

|UPPI

I

-

1998

Papillitis

in

a

Tlphoid

fever patient

with

toxic

encephalopathy and septic shock:

a rare

complication?

Primal

Sudjana,

Hadi

Jusuf

Abstrak

Demam tifoid masih menrpakan masalah umutn dan masaLah kesehatan rfiama di negara berkembang termasuk Intlonesia. Kom-plikasi clennrn tifuid tlapat mengenai berbagai organ seperti lraktus gastointestinal, hati, ginjal, susunan saraf pusat (SSP) dan lainnya. Komplikasi SSP di antaranya arkrlah ensefalopati toksik, meningitis dan ensefalitis. Satu kasus dentatn tifoid clengan kornplikasi

ense-fttlopati toksik, syok septik dan juga papilitis dilaporkan. Seorang wanita berusia 22 tahun dibawa ke RS karena panas, sakit kepala selama lebih dari 4 minggu dan 2 hari sebelum nnsuk kesadaran memburuk. Diagnosis demam tifoid ditegakkan setelah dikonfirmasikan dengan lnsiL ltositif Salmonella typhi pada kultur tlarah dan sumsr.tm tulang. Pemeriksaan _{funtluskopi memperlihatkan}aclanya edema papil bilateral dan tlitliagnosis sebagai suatu papillitis bilateral. Pasien diobati dengan antibiotik (kloramfenikol and sefalosporin), pem-berian cairan, kortikosteroitl dosis tinggi tlan obat inotropik. Setelah

j

nûnggu perawcûan, pasien pulang tlengan perbaikan klinis dan

2 nringgu kemudian papil kembali pada keaclaan normal tanpa adanya Bangtran penglihatan. Meskipun kami tidak mengkonfirntasi penyebab lain dari papillitis bilateral pada pasien ini, kami menyimpulkan bahwa papillitis tersebut merupakan suatu kotnplikasi dari demam tifoid.

Abtract

Tl,phoid fever is still prettalent and a major public lrcalth problem in developing countries including Indonesia. Typhoitl fever cont-plications involve various organ such as gastroùxtestinal tract ilself, Iive4 kidney, CNS and others. Atttottgs CNS complicalions are toxic enceplwlopathy, tneningitis and encephalitis. One typhoidfever case with loxic encephalopathy and septic shock cornplication who also complainecl visual clisturbance is reported. A 22 years oldfemale admitted to the hospital due to _feve4headache

for

ntore

tlnn

4 weeks and the consciousness deterioratecl tvvo elays

prior

to admission. Typhoidfever was confinnecl by both blood antl bone marrow posilive cttlture

for

Salmonella typhi. Funtluscopy revealed bilateral papiledetna and a bilateral papillitis was diagnosetl. The patient was treated with antibiotic, hemostatic sltpport, high dose corticosteroitl and vasopressor After 3 weeks of hospitalization the patient was disclurgecl from the hospitaL with clinical improvement and 2 weeks afterward the papil were back to normal. Since we did not confintl olher possibLe

cause of bilateral papillitis in this patient, we conch,tde that papilLitis is a complication of typhoitl fet,er

We report

a

typhoid fever

case

\ilith

toxic

ence-phalopathy

complicated

with

septic shock and

visual

disturbance.

CASE REPORT

A22

years

old housewife was

admitted to the

Hasan

Sadikin hospital

with

6 weeks

history

of

high fever,

headache and nausea.

Few days later

she

also

experi-enced productive

cough

and

then sought medication.

The

symptoms

were gradually

disappeared

but

re-mained subfebrile.

Twelve

days

before admission

the

body temperature suddenly rose and ten days later

she

became delirious.

On

admission

(May

15, 1997) the patient was

ob-served

as severely

ill

with

fever and delirium.

The

blood

pressure

was

105/60

mmHg, pulse

rate

116/min,

respiratory

rate24/min,

and body

tempera-ture 38.1"C. Neither

splenomegali

nor hepatomegali

was detected. Pathological reflexes and neck

rigidity

were not found. Laboratory

tests

revealed a

haemo-Clinical features and

pcrthogenesis

217

CP.1

INTRODUCTION

In

developing countries including

Indonesia,

typhoid

fever remains

as an

important public

health problem.

The

disease

is endemic

and

new

cases can be seen

all

year long.

In

Indonesia each year about 640,000

-1,500,000 cases

of

typhoid fever are reported with

mortality rate

of

1 .6

-

3

Vot.

In West Java; where this

case

took place;

in

1995, 25,877

typhoid fever

cases

were reported

and

9,887

cases !ù/ere

hospitalized

with

CFR

of

3.74

Vo

(V/est

Java

Health Profile,

1996).

Typhoid fever complication

may involve

both

intesti-nal

and

extra intestinal. Among extra

intestinal

com-plications,

acute confusional

state is the most

preva-lent2.

Infectious Disease Unit, Dept of Internal Medicine,

(2)

218

Typhoid Fever and other Salntonellosis

globin

of

12.6

g/dl,

white

blood

cell

count

was

5700/mm3,

platelet

142,000/mm3.

Ureum was

27.9

g/dl, creatinine 1.4 mg/dl, random blood

sugar

was

127

mg/dl. ECG

showed sinus tachycardia

and chest

X-ray

was

within normal

limit.

We suspected

typhoid

fever

with toxic

encephalopathy

as a

working

diagno-sis

with

tuberculosis meningitis

as

differential

diag-nosis.

The Neurologist found bilateral

papilledema

with

suspected

pseudotumor or papillitis

as

a cause.

Liquor

cerebrospinalis was

normal

and also

head

CT

scan.

Intravenous

chloramphenicol

500 mg

4

times

a

day

was administered, dexamethasone

3 mg/kg

body

weight

followed

with

1 mg/kg body weight every

6

hours was also given. On

May

17,

1997

the

patient

fell

into

septic shock

and

supportive

treatments

(dopamine etc.) were given. On

May

19,1997

the

pa-tients gained

consciousness and became

alert,

haemo-dynamic was stable and ophthalmologist was

con-sulted

due

to visual

disturbance

on

day

ten.

The visus

was

5112

in

both

eyes, and

papillitis

ODS

was

con-firmed. Blood culture

was

positive for

SalmonelLa

ty-phi.

After

19 days

of

hospitalization the patient

was

dis-charged

from hospital

with

normal both clinical

and

Iaboratory

profile.

On

follow up

3

months

later

the

visus was almost

normal (VOD

617 and

VOS

6/7).

DISCUSSION

Extra intestinal complication

of

typhoid fever

have

been reported

with

various organ involvement

in-cluding neuropsychiatric,

rnusculosceletal,

haemato-logical, renal,

ovary,

joint,

bone, spine

etc2'3.

Acute

confusional

state

is

the most common neurological

manifestationa's.

In

this

case

the length

of

fever prior

to

admission

is

quite unusual

for

typhoid fever,

perhaps

there

was

some

recovery after

receiving

treatrnent but

due

to

in-adequacy

oftreatment

it

relapsed (12

days

before

ad-mission). The patient was

severely

ill

,

delirious

and

although treatment was given

still

developed

septic

shock.

Although multidrug

-

resistant Salmonella

ty-phi

have been

widely

reported6,

in

our hospital

94.4

Med

J

Indones

Vo

of

S.

typhi

isolates are sensitive

to

chlorampheni-colz

which is

still

a

drug of

choice

for typhoid

fever.

Chloramphenicol 500 mg

was

given intravenously

4

times

a

day combined

with high

dose

dexamethasone

as

previously

reported8.

After

consciousness

was gained,

both

neurological

and

ophthalmological examinations

showed

the

evi-dence

of

bilateral

papillitis.

CT

scan

of

the

head

showed

no intracranial

masses.

On 3 months

follow

up the

visual sight

was

almost

normal.

According

to

our

knowledge

it

has

not

been

reported

earlier

a

typhoid fever

with

toxic

encephalopathy,

septic shock

and

bilateral papillitis. Since we could

not confirm

any other

possibilities which might

have

caused

papillitis

and

it

recovered

with

the

improve-ment

of

the

disease,

we

conclude

that

it

was a

com-plication

of typhoid

fever.

REFERENCES

I

.

Simanjuntak C. Epidemiology of typhoid fever in Indonesia,

Proc. International Symposia on Tropical and Infectious

Dis-eases Banduhg-Indonesia; 1 993.

2.

Mandal

BK.

Salmonella infections,

In:

G.C. Cook editor, Manson's Tropical Diseases, 20th ed, London: WB Saunders,

1996;849-63.

3,

Mandal BK. Salmonella infections. Medicine

1992l'5:4393-7.

4.

Khosla SN. Severe typhoid fever and appraisal of its profile In: R.H.H. Nelwan editor, Typhoid fever, Profile, Diagnosis

and Treatment in the 1990's 1992;753.

5.

Ali G, Rashid S, Kamli MA, Shah PA, Allaqaband GQ.

Spec-trum

of

neuropsychiatric complications

in

791 cases of ty-phoid fever. Trop Med Inter Health 1997:2:314-8.

6.

Gupta

A.

Multidrug-resistant typhoid

fever

in

children:

epidemiology and therapeutic approach. Pedjatr Infect Dis J

1994:13: 134-40.

7.

Sinaga H, Farwati

I,

Semaun E. Pola kepekaan Salmonella dari biakan gall terhadap antibiotika di RS Dr. Hasan Sadikin Bandung, Pekan Ilmiah FK Unpad 1996.

8.

Hoftman SL, Punjabi NH, Kumala S. Reduction of mortality

in

chloramphenicol-treated severe typhoid fever

by